HIPAA Notice of Privacy Practice

Definitions

Notice of Privacy Practices (The Notice)
– a written notice in compliance with the requirements of Health Insurance Portability and Accountability Act (HIPAA), and the Health Information Technology for Economic and Clinical Health Act (HITECH), enacted as part of the American Recovery and Reinvestment Act (ARRA) of 2009, made available from Trinity Health System to an individual or the individual’s personal representative at the first delivery of service, or at the individual’s next visit following a revision to the Notice, that describes the uses and disclosures of protected health information that may be made by Trinity Health System and the individual’s rights and Trinity Health System’s legal duties with respect to protected health information.

Protected Health Information (PHI)
– individually identifiable health information that is transmitted or maintained in any form or medium, including electronic media. Protected health information does not include employment records held by Trinity Health System in its role as an employer.

Trinity Health System, an affiliate member of Catholic Health Initiatives (CHI), and other affiliated members of CHI participate in an Organized Health Care Arrangement (OHCA) in order to share health information to manage joint operational activities. A complete list of CHI affiliated members is available at www.catholichealthinitiatives.org by clicking on “Locations”. A paper copy is available upon request. The CHI OHCA may use and disclose your health information to provide treatment, payment, or health care operations for the affiliated members and includes activities such as integrated information system management, health information exchange, financial and billing services, insurance, quality improvement, and risk management activities.

HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION

For Treatment. We will use your health information to provide you with health care treatment and to coordinate or manage services with other health care providers, including third parties. We may disclose all or any portion of your health information to your attending physician, consulting physician(s), nurses, technicians, health profession students, or other facility or health care personnel who have a legitimate need for such information in order to take care of you.

Different departments of the facility will share your health information in order to coordinate the health care services you need, such as prescriptions, lab work and X-rays. We may disclose your health information to family members or friends, guardians or personal representatives who are involved with your health care. We may also use and disclose your health information to contact you for appointment reminders and to provide you with information about possible treatment options or alternatives and other health-related benefits and services. We also may disclose your health information to people outside the facility who may be involved in your health care after you leave the facility, such as other physicians involved in your care, specialty hospitals, skilled nursing care facilities, and other healthcare-related services. We may use and disclose your health information to prescription networks to obtain your prescription benefits from payers, to obtain your medication history from different health care providers in the community such as pharmacies, and to send your prescriptions electronically to your pharmacy.

For Payment. We will use and disclose your health information for activities that are necessary to receive payment for our services, such as determining insurance coverage, billing, payment and collection, claims management, and medical data processing. For example, we may tell your health plan about a treatment you are planning in order to receive approval or to determine whether your plan will pay for the proposed treatment. We may disclose your health information to other health care providers so they can receive payment for health care services that they provided to you, such as your personal physician, and other physicians involved in your health care such as an anesthesiologist, pathologist, radiologist, or emergency physician, and ambulance services. We may also give information to other third parties or individuals who are responsible for payment for your health care, such as the named insured under the health policy who will receive an explanation of benefits (EOB) for all beneficiaries who are covered under the insured’s plan.

For Health Care Operations. We may use and disclose your health information for routine facility operations, such as business planning and development, quality review of services provided, internal auditing, accreditation, certification, licensing or credentialing activities (including the licensing or credentialing activities of health care professionals), medical research and education for staff and students, assessing your satisfaction with our services, and to other healthcare entities that have a relationship with you and need the information for operational purposes. We may use and disclose your health information to the external agencies responsible for oversight of health care activities such as The Joint Commission, external quality assurance and peer review organizations, and credentialing organizations. We may also disclose health information to business associates we have contracted with to perform services for or on our behalf such as patient satisfaction survey organizations. We may also disclose your health information to medical device manufacturers or pharmaceutical companies in order for those companies to carry out their legal obligations to state and federal agencies.

CHI Health Information Exchange. Trinity Health System, as a member of the CHI OHCA, participates in the CHI Health Information Exchange (HIE). Your health information is maintained electronically and healthcare providers, employed, under contract, or otherwise associated with Trinity Health System, and the CHI OHCA members may access, use, and disclose your health information for treatment, payment, and healthcare operations.

Ohio CliniSync is Ohio’s statewide Health Information Exchange (HIE) that is operated by the Ohio Health Information Partnership (OHIP). Trinity Health System participates with CliniSync. As permitted by law, your health information will be shared with this exchange in order to provide faster access to care, better coordination of care, and assist providers and public health officials in making more informed decisions. CliniSync maintains appropriate administrative, physical, and technical safeguards to protect the privacy and security of your protected health information. Only authorized individuals may access and use your protected health information from CliniSync. You or your personal representative has the right to request in writing that we 1) Not disclose any of your protected health information to CliniSync, or 2) Not disclose specific categories of your protected health information to CliniSync.

You may ‘opt-out’ or restrict the sharing of your health information to CliniSync at any time. Any restrictions on the disclosure of your information may result in a health care provider not having access to information that is necessary for the provider to render appropriate care to you. Any reasonable restrictions you place on the disclosure of your protected health information will be honored by Trinity Health System. You may opt-out of CliniSync or restrict the sharing of your information with CliniSync by contacting your medical provider directly or by completing and submitting the “Request to Change Consent” form, and sending it to your medical provider or to Att: CONSENT STATUS, Ohio Health Information Partnership, 3455 Mill Run Drive, Suite 315, Hilliard, OH 43026.

Facility Directory. The hospital facility directory is available so that your family, friends, and clergy can visit you and generally know how you are doing while in the hospital. We may include your name, location in the facility, your general condition (for example, fair or stable), and your religious affiliation in the facility directory. The directory information, except for your religious affiliation, may be released to people who ask for you by name. Your name and religious affiliation may be given to a member of the clergy such as a priest or rabbi, even if they don’t ask for you by name. You must notify Patient Access at (740) 264-8000 verbally or in writing at 4000 Johnson Road, Steubenville, OH 43952, if you do not want us to release information about you in the facility directory. If you do not want information released in the facility directory, we cannot tell members of the public such as flower or other delivery services or friends and family that you are here or about your general condition.

Future Communications. We may provide communications to you with newsletters or other means regarding treatment options, health related information, disease management programs, wellness programs, or other community based initiatives or activities in which our facility is participating.

Fundraising Activities. We may use your health information, or disclose your health information to a foundation related to us for Trinity Health System’s fundraising efforts. These funds would be used to expand and improve services and programs we provide to the community. We would only release information such as your name, address, other contact information, age, gender, dates of birth, health insurance status, the dates you received treatment or services from us, the department of service and the outcome of those services. Trinity Health System will not condition treatment or payment for services on an individual’s participation in fundraising. You have a right to opt out of receiving such communications. To opt out of these communications, contact Trinity Health System Foundation at (740) 264-8000 or by mail at 4000 Johnson Road, Steubenville, OH 43952.

Research. We may use and disclose your health information to researchers either when you authorize the use and disclosure of your health information, or an Institutional Review Board and/or Privacy Board approves an authorization waiver for the use and disclosure of your health information for a research study. A waiver may allow a researcher to use or disclose your health information to prepare for research, to screen and identify participants for inclusion in a research study, or to conduct research on a decedent’s information.

Organ and Tissue Donation. If you are an organ donor, we may release your health information to organizations that handle organ procurement and transplantation or to an organ donation bank as necessary to facilitate organ or tissue donation and transplantation.

USES AND DISCLOSURES THAT ARE REQUIRED OR PERMITTED BY LAW

Subject to requirements of federal, state and local laws, we are either required or permitted to report your health information for various purposes. Some of these reporting requirements and permissions include:

Public Health Activities. We may disclose your health information to public health officials for activities such as for the prevention or control of communicable disease, bioterrorism, injury, or disability; to report births and deaths; to report suspected child, elder, or spouse abuse or neglect; to report reactions to medications or problems with medical products; to report information to the federal Centers for Disease Control or to authorized national or state cancer registries for their data aggregation.

Disaster Relief Efforts. We may disclose your health information to an entity assisting in a disaster relief effort, such as the American Red Cross, so that your family can be notified about your condition and location.

Health Oversight Activities. We may disclose your health information to a health oversight agency for activities authorized by law. Such agencies include federal Centers for Medicare and Medicaid Services, and state health professional oversight agencies or boards such as state medical or nursing boards. These oversight activities may include audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor activities such as health care treatment and spending, government programs, and compliance with civil rights laws.

Judicial or Administrative Proceeding. We may disclose your health information in response to a legal court or administrative order, a subpoena, discovery request, civil or criminal proceedings, or other lawful process.

Law Enforcement. We may release your health information if asked to do so by a law enforcement official or if we have a legal obligation to notify the appropriate law enforcement or other agencies:

Coroners, Medical Examiners and Funeral Directors. We may release health information to a coroner or a medical examiner. This may be necessary to identify a person who died or to determine the cause of death. We may release health information to help a funeral director to carry out his/her duties.

Workers' Compensation. We may release your health information for workers’ compensation benefits or similar programs that provide benefits for work-related injuries or illnesses if you tell us that workers’ compensation is the payer for your visit(s). Your employer or their workers’ compensation carrier may request the entire medical record pertinent to your workers’ compensation claim. This medical record may include details regarding your health history, current medications you are taking, and treatments.

To Avert a Serious Threat to Health or Safety. We may disclose your health information when necessary to prevent a serious threat to your health and safety or the health and safety of another person or the public.

National Security. We may disclose your health information to federal official(s) for national security activities and for the protection of the President and other Heads of State.

Military and Veterans. If you are a member of the armed forces, we may release your health information as required by military command authorities. We may also release health information about foreign military personnel to the appropriate foreign military authority.

Inmates. If you are an inmate of a correctional institution or in the custody of a law enforcement official, we may release your health information to the institution or law enforcement official. This release would be necessary for the institution to provide you with health care, to protect your health and safety or the health and safety of others, or for the safety and security of the correctional institution.

OTHER USES AND DISCLOSURES OF YOUR HEALTH INFORMATION

Other uses and disclosures of your health information not covered by this notice or the laws that apply to Trinity Health System will be made only with your written authorization. If you provide us with authorization to use or disclose your health information, you may revoke that authorization in writing at any time. When we receive your written revocation we will no longer use or disclose your health information for the purpose of that authorization. However, we are unable to retrieve any disclosures already made based on your prior authorization.

Trinity Health System will obtain your authorization to use and disclose your health information for these specific purposes when required by law and regulation:

Marketing. Marketing is a communication about a product or service that you may be interested in purchasing. If Trinity Health System receives payment from a third party in order for Trinity Health System to promote the product or service to you, then Trinity Health System is required to obtain your written authorization before we can use or disclose your health information. Trinity Health System is not required to obtain your authorization to discuss with you Trinity Health System health care treatment options, health-related products, case management or care coordination, or to direct or recommend alternative treatments, therapies, providers, or settings of care, providing face to face discussions and offering samples or promotional gifts of nominal value. You have the right to revoke your marketing authorization and Trinity Health System will honor the revocation. To opt out of these communications, please contact Marketing and Communications at (740) 264-8000 or by mail at 4000 Johnson Road, Steubenville, OH 43952.

Psychotherapy Notes. Psychotherapy notes are notes by a mental health professional that document or analyze the contents of a conversation during a private counseling session or a group, joint, or family counseling session. If psychotherapy notes are maintained separate from the rest of your health information they may not be used or disclosed without your written authorization, except as may be required by law.

Sensitive Medical Information. We may obtain a separate authorization from you, when required by specific state and federal laws, to use or disclose sensitive medical information, such as psychiatric, substance abuse, infectious disease, or genetic testing information.

Sale of Health Information. Trinity Health System will obtain your authorization for any disclosure of your health information which Trinity Health System directly or indirectly receives remuneration in exchange for the health information.

THIS NOTICE DOES NOT APPLY TO THE FOLLOWING HEALTH RELATED ACTIVITES

Some activities of Trinity Health System may not be covered by this notice. If you seek services at wellness or health fairs, for occupational health services, employee health related services, or direct access lab services this notice and its components do not apply.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

You have the following rights regarding your health information:

Right to Inspect and Copy. You have the right to inspect your health information and receive a copy of medical, billing, or other records that may be used to make decisions about your care. The right to inspect and receive a copy may not apply to psychotherapy notes that are maintained separately from your health information.

Your request to inspect and receive a copy of your health information must be submitted in writing. We may charge a fee for document requests to cover the costs of copying, mailing, or other supplies. You have the right to request your health information in electronic format. Trinity Health System will provide your health information in the form and format you request, if feasible, or in a mutually agreeable form and format.

Submit your request in writing using our “Authorization for Use or Disclosure of Protected Health Information” form to the Health Information Management Department. For assistance call Health Information Management at (740) 264-8000 or by mail at 4000 Johnson Road, Steubenville, OH 43952.

In limited circumstances we may deny your request to inspect or receive a copy of your health information. If we deny your request we will notify you of the reason. If you are denied access to your health information, you may request that the denial be reviewed. A licensed health care professional chosen by Trinity Health System will review your request and the denial. The person who conducts the review will not be the same person who denied your request. We will comply with the outcome of the review.

Right to Amend. You have the right to request an amendment to your health information that you believe is incorrect or incomplete.

Submit your request in writing, including your reason for the amendment, using our “Request for Amendment to PHI” form and send to Health Information Management Department at (740) 264-8000 or by mail at 4000 Johnson Road, Steubenville, OH 43952. For assistance call Health Information Management Department at (740) 264-8000

We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. We may also deny your request if you ask us to amend information that:

Right to an Accounting of Disclosures. We are required to maintain a list of certain disclosures of your health information. However, we are not required to maintain a list of disclosures that we made by acting upon your written authorizations. You have the right to request an accounting of disclosures that are not subject to your written authorization.

Submit your request in writing using our “Request for Accounting of Disclosures of PHI” form and send to Health Information Management Department at 4000 Johnson Road, Steubenville, OH 43952. For assistance call Health Information Management Department at (740) 264-8000. Your request must state a time period, not longer than six years from the date of request. The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request before any costs are incurred.

Right to Request Restrictions. You have the right to request a restriction or limitation on how much of your health information we use or disclose for treatment, payment, or health care operations. You also have the right to request a restriction on the disclosure of your health information to someone who is involved in your care or payment for your care, such as a family member or friend.

We are not required to agree to your request. However, if we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment.

You have the right to request that we restrict the disclosure of your information to a health plan regarding a specific health care item or service that you, or someone on your behalf (other than a health plan), has paid for in full. We are required to comply with your request for this specific type of restriction. For example, if you sought counseling services and paid in full for the services rather than submitting the expenses to a health plan, you may request that your health information related to the counseling services not be disclosed to your health plan.

Submit your request in writing or request and submit a “Request for Restrictions to Use or Disclose Protected Health Information” form and send to Health Information Management Department at 4000 Johnson Road, Steubenville, OH 43952. For assistance call Health Information Management Department at (740) 264-8000. You must include: a description of the information that you want to restrict, whether you want to restrict our use or disclosure or both; and to whom you want the restriction to apply.

Right to Request Confidential Communications. You have the right to request that we communicate with you about health care matters in a certain way or at a certain location. For example, you can ask that we only contact you at an alternative location from your home address, such as work, or only contact you by mail instead of by phone. Your request must specify how or where you wish to be contacted. We do not require a reason for the request. We will accommodate all reasonable requests.

Right to Receive Notice of a Privacy Breach. You have the right to receive written notification if Trinity Health System discovers a breach of unsecured protected health information involving your health information. Breach means the unauthorized acquisition, access, use, or disclosure of protected health information which compromises the security or privacy of the information. The Notice will include a description of the breach, health information involved, steps we have taken to mitigate the breach, and actions that you may need to take in response to the breach.

Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. If you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You may ask us to give you a copy of this notice at any time.

To ask questions about any of these rights, or to obtain a paper copy of this notice, contact the Privacy Officer at (740) 264-8000 or in writing at 4000 Johnson Road, Steubenville, OH 43952. Or, you may obtain a copy of this notice at our Web site, www.trinityhealth.com.

CHANGES TO THIS NOTICE

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for health information we already have about you and for any information we may receive in the future. We will post a copy of the current notice in the facility and on our web site (if applicable) at www.trinityhealth.com. The notice will contain the effective date. Upon your initial registration or admittance to the facility for treatment or health care services as an inpatient or outpatient, we will offer you a copy of the notice currently in effect. Whenever the notice is revised, it will be available to you upon request.

COMPLAINTS

You may file a complaint with us or with the Secretary of the Department of Health and Human Services if you believe that we have not complied with our privacy practices.

You may file a complaint with us by contacting the Privacy Officer at (740) 264-8000 or in writing at 4000 Johnson Road, Steubenville, OH 43952.

If you file a complaint, we will not take any action against you or change our treatment of you in any way.

If you have any question about this notice please contact the
Trinity Health System Privacy Officer

4000 Johnson Road • Steubenville, Ohio 73952
740-264-8000

Form No. 8115-657-01/2017

Trinity Health System

Notice of
Privacy
Practices
Effective Date: 01/2017THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

If you have any questions about this notice, please contact thePrivacy Officer (740) 264-8000

NOTICE OF PRIVACY PRACTICES Effective April 14, 2003 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. As part of the federal Health Insurance Portability and Accountability Act of 1996, known as HIPAA, the pharmacy has created this Notice of Privacy Practices (Notice). This Notice describes the pharmacy's private practices and the rights you, the individual, have as they relate to the privacy of your Protected Health Information (PHI). Your PHI is information about you, or that could be used to identify you, as it relates to your past and present physical and mental health care services. The HIPAA regulations require that the pharmacy protect the privacy of your PHI that the pharmacy has received or created. This pharmacy will abide by the terms presented within this Notice. For any uses or disclosures that are not listed below, the pharmacy will obtain a written authorization from you for that use or disclosure, which you will have the right to revoke at any time, as explained in more detail below. The pharmacy reserves the right to change the pharmacy's privacy practices and this Notice. Revisions to the Notice will be posted in the pharmacy and upon your request, provided to you in a paper format. HOW THE PHARMACY MAY USE AND DISCLOSE YOUR PHI The following is an accounting of the ways that the pharmacy is permitted, by law, to use and disclose your PHI. Uses and disclosures of PHI for Treatment: We will use the PHI that we receive from you to fill your prescription and coordinate or manage your health care. Uses and disclosures of PHI for Payment: The pharmacy will disclose your PHI to obtain payment or reimbursement form insurers for your health care services. Uses and disclosures of PHI for Health Care Operations: The pharmacy will use your PHI to conduct quality assessments, improvement activities, and evaluate the pharmacy workforce. The following is an accounting of additional ways in which the pharmacy is permitted or required to use or disclose phi about you without your written authorization: Uses and disclosures as required by law: The pharmacy is required to use and disclose PHI about you as required and as limited by law. Uses and disclosures for public health activities: The pharmacy may use or disclose PHI about you to a public health authority that is authorized by law to collect for the purpose of preventing, controlling disease, injury, or disability. Uses and disclosure about victims of abuse, neglect or domestic violence: The pharmacy may use or disclose PHI about you to a government authority if it is reasonably believed you are a victim of abuse, neglect or domestic violence. Uses and disclosures for health oversight activities: The pharmacy may use or disclose PHI about you to a health oversight agency for oversight activities that it is authorized by law to conduct. Disclosures for judicial and administrative proceedings: The pharmacy may disclose PHI about you in the course of any judicial or administrative proceedings, provided that proper documentation is presented to the pharmacy. Disclosures for law enforcement purposes: The pharmacy may disclose PHI about you to law enforcement officials for authorized purposes. Uses and disclosures about the deceased: The pharmacy may disclose PHI about a deceased, or prior to, and in reasonable anticipation of an individual's death, to coroners, medical examiners, and funeral directors. Uses and disclosures for cadaveric organ, eye or tissue donation purposes: The pharmacy may use and disclose PHI for the purpose of procurement, banking, or transplantation of cadaveric organs, eyes, or tissues for donation purposes. Uses and disclosures for research purposes: The pharmacy may use and disclose PHI about you for research purposes with valid waiver of authorization approved by an institutional review board or a privacy board. Otherwise, the pharmacy will request a signed authorization by the individual for all other research purposes. Uses and disclosures to avert a serious threat to health or safety: The pharmacy may use or disclose PHI about you, if it believed in good faith, and is consistent with any applicable law and standards of ethical conduct, to avert a serious threat to health or safety. Uses and disclosures for specialized government functions: The pharmacy may use or disclose PHI about you for specialized government functions including; military and veteran's activities, national security and intelligence, protective services, department of state functions, and correctional institutions and law enforcement custodial situations. Disclosure for workers' compensation: The pharmacy may disclose PHI about you as authorized by and to the extent necessary to comply with workers' compensation laws or programs established by law. Disclosures for disaster relief purposes: The pharmacy may disclose PHI about you as authorized by law to a public or private entity to assist in disaster relief efforts. Disclosures to business associates: The pharmacy may disclose PHI about you to the pharmacy's business associates for services that they may provide to or for the pharmacy. OTHER USES AND DISCLOSURES The pharmacy may contact you for the following purposes: Refill reminders: The pharmacy may contact you to remind you of your prescription upon such time they are ready to be refilled. Information about treatment alternatives: The pharmacy may contact you to notify you of alternative treatments and/or products. Health related benefits or services: The pharmacy may use your PHI to notify you of benefits and services the pharmacy provides. Fundraising: If the pharmacy participates in a fundraising activity, the pharmacy may use demographic PHI to send you a fundraising packet, or the pharmacy may disclose demographic PHI about you to its business associate or an institutionally related foundation to send you a fundraising packet. No further disclosure will be allowed by the business associates or an institutionally related foundation without your written authorization. FOR ALL OTHER USES AND DISCLOSURES The pharmacy will obtain a written authorization from you for all other uses and disclosures of PHI, and the pharmacy will only use or disclose pursuant to such an authorization. In addition, you may revoke such an authorization in writing at any time. To revoke a previously authorized use or disclosure, please contact the pharmacy. YOUR HEALTH INFORMATION RIGHTS The following are a list of your rights in respect to your PHI. Request restrictions on certain uses and disclosures of your PHI: You have the right to request additional restrictions of the pharmacy?s uses and disclosures of your PHI; however, the pharmacy is not required to accommodate a request. If you wish to request additional restrictions, please obtain the form, Request for Restriction of Uses & Disclosures, from the pharmacy and return the completed form to the pharmacy. The right to have your PHI communicated to you by alternate means or locations: You have the right to request that the pharmacy communicate confidentially with you using an address or phone number other than your residence. However, state and federal laws require the pharmacy to have an accurate address and home phone number in case of emergencies. The pharmacy will consider all reasonable requests. If you wish to request a change in your communicating address and/or phone number, please obtain a form, Request for Alternative Arrangements for Confidential Communication, from the pharmacy and return the completed form to the pharmacy. The right to inspect and/or obtain a copy of your PHI: You have the right to request access and/or obtain a copy of your PHI that is contained in the pharmacy for the duration the pharmacy maintains PHI about you. If you wish to inspect or obtain a copy of your PHI, please obtain a form, Request for Access to Records, from the pharmacy and return the completed form to the pharmacy. There may be a reasonable cost-based charge for photocopying documents. You will be notified in advance of incurring such charges, if any. The right to amend your PHI: You have the right to request an amendment of the PHI the pharmacy maintains about you, if you feel that the PHI the pharmacy has maintained about you is incorrect or otherwise incomplete. Under certain circumstances we may deny your request. If we do deny the request, you will have the right to have the denial reviewed by someone we designate who was not involve in the initial review. You may ask to Secretary, United States Department of Health and Human Services, or their appropriate designee, to review such a denial. If you wish to amend your PHI files, please obtain a form, Request for Amendment of PHI, from the pharmacy and return the completed form to the pharmacy. The right to receive and accounting of disclosures of your PHI: You have the right to receive an accounting of certain disclosures of your PHI made by the pharmacy. If you wish to receive an accounting of disclosures of your PHI, please obtain form, Request for Accounting of Disclosures, from the pharmacy and return the completed form to the pharmacy. You should be aware; however, that such an accounting excludes uses and disclosures made for treatment, payment and health care operations purposes. The right to receive additional copies of the Pharmacy?s Notice of Privacy Practices: you have the right to receive additional paper copies of this Notice, upon request, even if you initially agreed to receive the Notice electronically. If you with to receive a paper copy of this notice, please ask a pharmacy workforce member and they will provide you with a copy. REVISIONS TO THE NOTICE OF PRIVACY PRACTICES The pharmacy reserves the right to change and/or revise this Notice and make the new revised version applicable to all PHI received prior to its effective date. The revised Notice will be available, upon request, to all individuals. The pharmacy will also post the revised version of the Notice in the pharmacy. COMPLAINTS If you believe your privacy rights have been violated, you may file a complaint with the pharmacy and/or to the Secretary of HHS, or his designee. If you wish to file a complaint with the pharmacy, please contact the Privacy Officer. If you wish to file a complaint with the Secretary, please write to: The U.S. Department of Health and Human Services Office of the Inspector General 200 Independence Ave, S.W. Washington, D.C. 20201 The pharmacy will not take any adverse action against you as a result of your filing of a complaint. CONTACT INFORMATION If you have any questions on the pharmacy's privacy practices or for clarification on anything contained within the Notice, please contact: